Fillable Form 13614-C - Intake/interview & Quality Review Sheet printable pdf download

Form 13614-C - Intake/interview & Quality Review Sheet

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13614-C

Department of the Treasury - Internal Revenue Service

OMB Number

Form

Intake/Interview & Quality Review Sheet

1545-1964

(October 2016)

You will need:

• Please complete pages 1-3 of this form.

• Tax Information such as Forms W-2, 1099, 1098, 1095.

• You are responsible for the information on your return. Please provide

• Social security cards or ITIN letters for all persons on your tax return.

complete and accurate information.

• Picture ID (such as valid driver's license) for you and your spouse.

• If you have questions, please ask the IRS-certified volunteer preparer.

Volunteers are trained to provide high quality service and uphold the highest ethical standards.

To report unethical behavior to the IRS, email us at wi.voltax@irs.gov

Part I – Your Personal Information (If you are filing a joint return, enter your names in the same order as last year’s return)

1. Your first name

M.I.

Last name

Telephone number

Are you a U.S. citizen?

Yes

2. Your spouse’s first name

M.I.

Last name

Telephone number

Is your spouse a U.S. citizen?

Yes

3. Mailing address

Apt #

City

State

ZIP code

4. Your Date of Birth

5. Your job title

6. Last year, were you:

a. Full-time student

Yes

b. Totally and permanently disabled

c. Legally blind

Yes

9. Last year, was your spouse:

a. Full-time student

Yes

7. Your spouse’s Date of Birth

8. Your spouse’s job title

b. Totally and permanently disabled

Yes

c. Legally blind

Yes

10. Can anyone claim you or your spouse on their tax return?

Yes

Unsure

11. Have you or your spouse:

a. Been a victim of identity theft?

Yes

b. Adopted a child?

Yes

Part II – Marital Status and Household Information

1. As of December 31, 2016, were

Unmarried

(This includes registered domestic partnerships, civil unions, or other formal relationships under state law)

you:

Married

Yes

a. If Yes, Did you get married in 2016?

Yes

b. Did you live with your spouse during any part of the last six months of 2016?

Date of final decree

Divorced

Date of separate maintenance agreement

Legally Separated

Year of spouse’s death

Widowed

2. List the names below of:

If additional space is needed check here

and list on page 3

• everyone who lived with you last year (other than your spouse)

• anyone you supported but did not live with you last year

To be completed by a Certified Volunteer Preparer

Name (first, last) Do not enter your

Date of Birth

Relationship

Number of

Resident

Single or

Full-time

Totally and

Is this

Did this

Did the

name or spouse’s name below

(mm/dd/yy)

to you (for

months

Citizen

of US,

Married as

Student

Permanently

person a

person

taxpayer(s)

example:

lived in

(yes/no)

Canada,

of 12/31/16

last year

Disabled

qualifying

provide

have less

provide more

pay more than

son,

your home

or Mexico

(S/M)

(yes/no)

child/relative

more than

than $4,050

than 50% of

half the cost of

daughter,

last year

of any other

50% of his/

of income?

support for

maintaining a

parent,

(yes/no)

person?

her own

(yes/no)

this person?

home for this

none, etc)

(yes/no)

support?

(yes/no/N/A)

person?

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(yes/no)

13614-C

Catalog Number 52121E

Form

(Rev. 10-2016)

Form 13614-C - Intake/interview & Quality Review Sheet

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